Trainee-Associated Factors and Proficiency at Percutaneous Nephrolithotomy.

Percutaneous nephrolithotomy (PNL) is a complicated procedure for urology trainees. This study was designed to investigate the effect of trainees' ages and previous experience, as well as the number of operated cases, on proficiency at PNL by using patient outcomes. A cross sectional observational study was designed during a five-year period. Trainees in PNL fellowship programs were included. At the end of the program, the trainees' performance in PNL was assessed regarding five competencies and scored 1-5. If the overall score was 4 or above, the trainee was considered as proficient. The trainees' age at the beginning of the program and the years passed from their residency graduation were asked and recorded. Also, the number of PNL cases operated by each trainee was obtained via their logbooks. The age, years passed from graduation, and number of operated cases were compared between two groups of proficient and non-proficient trainees. Univariate and multivariate binary logistic regression analysis was applied to estimate the effect of aforementioned variables on the occurrence of the proficiency. Forty-two trainees were included in the study. The mean and standard deviation for the overall score were 3.40 (out of 5) and 0.67, respectively. Eleven trainees (26.2%) recognized as proficient in performing PNL. Univariate regression analysis indicated that each of three variables (age, years passed from graduation and number of operated cases) had statistically significant effect on proficiency. However, the multivariate regression analysis revealed that just the number of cases had significant effect on achieving proficiency. Although it might be assumed that trainees' age negatively correlates with their scores, in fact, it is their amount of practice that makes a difference. A certain number of cases is required to be operated by a trainee in order to reach the desired competency in PNL.

Feasibility of totally tubeless percutaneous nephrolithotomy under the age of 14 years: a randomized clinical trial.

OBJECTIVE: To assess the outcome and safety of the totally tubeless percutaneous nephrolithotomy (PCNL) in comparison with standard PCNL in the children under the age of 14 years. PATIENTS AND METHODS: Twenty-three patients under the age of 14 with renal stones were enrolled in a prospective randomized clinical trial during March 2010 to June 2011. The inclusion criteria were existence of renal stone larger than 2.5 cm in diameter or extracorporeal shockwave lithotripsy-resistant kidney stone; furthermore, exclusion criteria were kidney anomalies, renal failure on admission, and serious bleeding or perforation in the collecting system during the operation. The patients were divided into two groups according to block randomization. Group A comprised of 13 children with mean age 10.31 (4-14) years, were rendered totally tubeless at the end of surgery, while 10 patients in group B with mean age 11.1 (9-14) years underwent standard PCNL. The incidence of complications, transfusion rate, analgesic use, hemoglobin drop, operation time, and hospital stay were compared between the two groups during a one-month study period. RESULTS: The mean stone burden was 29.23 mm (SD=4.85) in group A versus 31.4 mm (SD=5.19) in group B. Hospitalization averaged 39.54 (SD=11.39) hours versus 58.7 (SD=10.37) (p<0.001) and the average analgesics use was 0.07 (SD=0.03) mg/kg of morphine versus 0.15 (SD=0.04) (p<0.001), respectively. Operation time, transfusion rate, complications, retreatment, and hemoglobin drop were not different, significantly. CONCLUSION: Totally tubeless PCNL for pediatric population yields decreased hospital stay and analgesic use with no more complications. So, it can be considered as a standard and cost-beneficial procedure in appropriately selected group of patients.

Is antibiotic prophylaxis necessary in patients undergoing ureterolithotripsy?

Transurethral Ureterolithotripsy (TUL) is a frequently used procedure in urology departments. Many urologists perform TUL without antibiotic prophylaxis; however the use of chemoprophylaxis before TUL remains a controversial issue in urology. This study was carried out to assess the safety of omitting antibiotic prophylaxis prior to TUL. In a prospective randomized clinical trial from January 2005 to December 2007, 114 patients with ureteral stones were enrolled; Fifty seven had preoperative antibiotic prophylaxis administered before TUL and fifty seven patients underwent TUL without antibiotic prophylaxis. The rate of postoperative infectious complications (fever, positive blood culture, significant bactriuria), the length of hospital stay and overall stone free rate were compared between the two groups. There was no statistically significant difference between two groups in the operation time, length of hospital stay, postoperative bacteriuria, positive urine culture, postoperative fever and overall success rate of TUL. It appears that the incidence of infectious complications does not increase in patients undergoing TUL without antibiotic prophylaxis if they have negative pre-operative urine culture and antiseptic technique have been performed thorough the procedure.

Effects of prophylactic insertion of Double-J stents to decrease episodes of renal colic in patients with recurrent ureteral stones.

PURPOSE: To evaluate the hypothesis that prophylactic insertion of Double-J stents after uncomplicated transurethral lithotripsy (TUL) can decrease the number of episodes of renal colic and their intensity in patients with recurrent ureteral stones (those with three or more episodes of stone formation). PATIENTS AND METHODS: During a prospective randomized clinical trial from May 1999 to January 2004, 195 patients with recurrent ureteral stones were included in our study; 94 had stents in place for 4 weeks, and 101 patients remained stentless (control group). A few patients in each group had residual stone disease. All patients were followed-up for a mean period of 24 months and questioned about the number and intensity of their episodes of renal colic, and were also evaluated for their rates of spontaneous stone passage. RESULTS: Spontaneous passage of stones was seen in 43 patients (45.7%; CI 95%, 35.7, 55.8) who underwent stenting, and 35 patients (34.7%; CI 95%, 25.4, 43.9) in the stentless group (P > 0.05). The number of episodes of renal colic was significantly lower in the stented group (P < 0.001). CONCLUSION: Insertion of Double-J stents for 4 weeks after uncomplicated TUL in patients with recurrent ureteral stones significantly decreases the number of episodes of ureteral colic, although it does not decrease the rate of stone formation.